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Krugman on raising the Medicare eligibility age and how this affects lower income seniors. The urgent need to rein in health care costs in the U.S. as other countries have done.

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This is an exceptionally humorous operating room story of Dr. Trump and Dr. McConnell by Kristof of the NYT. Sometimes humor tells the story- and Kristof does this using a story of a surgeon president Trump in the operating Room trying to address the concerns of the patient Janet, as he keeps telling her she needs a new heart with great benefits, great benefits, before she implodes or goes down failing. Flat out take the old heart out even if a replacement hasn't been found, believe me great benefits the surgeon tells her, just that the patient just isn't getting convinced as its happening to her. The analogy is with replacing a health care plan, not just the Obama plan, any plan without something to take its place. For a few days before this article by Kristof, the Republican effort to repeal the Affordable Care Act without having a replacement was presented as a good idea. Janet is like the three Republican women- Collins of Maine, Capito of West Virginia, and Murkowski of Alaska who wanted to keep the heart they had till a replacement was found, against the surgeon Trump's advice. In a way it is about politicians in the last decade who never had any discussions as they rushed through with their own agendas, as the Republican and Democratic health care plans were rushed through Congress with relatively little participation and debate to hear all viewpoints. ...

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Bowles and Simpson call for deficit savings along the lines they suggested as co-chairmen of the President's Deficit Commission- reducing the cost increases in Medicare, changes to Social Security, and cutting tax expenditures.

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Krauthammer says there is reason for optimism that the super committee of the August 2 Debt Ceiling and Deficit bill can achieve major results. The reason he says is that much of the work in key areas has already been worked out by the Simpson-Bowles Commission. This has also received extensive public scrutiny and discussion. Its now upto the committe to make some choices for tax reform. For the sake of efficiency and fairness this needs to be done. Efficiency is gained by closing the loopholes and the tax exemptions for mortgage interest deductions, health-care exclusion, and subsidies such as the one for ethanol. And in its place moving to lower tax rates, the 23% envisaged by Simpson-Bowles, or the 28% from the Reagan days, down from the 35% today. Fairness is gained by removing tax breaks for special interest groups that do much of the lobbying. The mortgage interest deduction can be phased out starting at $500,000 in the inital phase or using the plan for tax expenditures proposed by Martin Feldstein. Feldstein's proposal outlined in the New York Times on May 4, 2011, (see group for Feldstein) was to limit the reduction in taxes from deductions and exclusions to 2% of the person's AGI or adjusted gross income. The other part of the Committee's focus would be the structural changes to Social Security and Medicare- raising the Social Security and Medicare ages and changing the inflation formula, and means testing Social Security. Obama has already considered the raising of the age for Social Security and changing the cost of living formula....

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Pearlstein raises the question, are there business leaders who believe that what's good for America, is good for business, rather than the other way around. Google, like other technology companies, pays much less in taxes than the corporate tax rate suggests. Research by the Washington Post shows this to be 18%, not 35%, for 2009.

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EU leaders and proposals to limit tax avoidance by digital companies by requiring the companies to show the profits in the countries where they are made. This would require changing bilateral treaties. France is looking at proposals to tax companies by the number of clicks or user data. Large digital companies, including Apple and Google declare most of their European revenue in Ireland using legal loopholes in that country to shift profits to lower tax locations. A Senate report in the U.S. in May 2013 shows Apple using technicalities in Irish and U.S. laws to pay only a small amount in corporate taxes in four years 2009-2012 on $74 billion. Fredrik Reinfeldt, the prime minister of Sweden stated the argument for fairness in tax policy- "These companies ask for a lot of investment in infrastructure, in research and development, they want to have well educated staff members. Well, let's keep that together: Pay your taxes so we can afford all of these investments."

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Details of the $825 billion stimulus plan. Renewable energy does well under the plan including production tax credit for renewables, with $32 billion for a "smart" electrical grid for which GE makes components and lobbied for. Renewable energy producers win an extension of production tax credits now convertible into cash for companies whose losses leave them unable to use the credits. Transportation infrastructure green projects did not do so well, with $32 billion for transportation projects and only $10 billion for mass transit projects.The Natural Resources Defense Council had compiled a list of more than 80 environmentally friendly infrastructure and transportation projects worth about $405 billion. Only a small number of these projects made it. What is in the stimulus to create jobs and stimulate capital investment? Businesses get bonus depreciation, which speeds up depreciation deductions for companies that invest in plant and equipment. The stimulus doubles the amount small businesses can immediately write off for capital investments and purchasing new eqipment, and gives incentives for businesses to invest in renewable energy. States get help with $90 billion going to increase the federal share of Medicaid payments, and an additional $79 billion to help states avoid cutbacks in education and other services. And there is a "Make Work Pay" tax credit for $500 per worer and $1000 per couple. Experts say the effects of the stimulus will be felt in the latter part of 2009 and into 2010. Which is one reason the view of economists that there would be a second half recovery does not reflect conditions on the ground. Goldman has revised its view to 2010 and even that may be optimistic. One example of what has happened in the stimulus in this respect is that the earlier optimistic view of largeinvestments in science and technology, broadband networks, and transportation projects for fast rail and transit have all been trimmed down. Part of the reason may be that the bill for the nation's banking system revival may be larger than realized as an additional amount of $15-20 billion is being negotiated for Bank of America and more money will go to Citigroup. $6 billion is shown for highspeed internet access for rural and underserved areas. Science facilities get $10 billion. Repair of public infrastructure (read roads and bridges) gets $31 billion. School modernization gets $21 billion. And modernization of health information technology systems gets $20 billion which its hoped will provide equivalent or higher returns to pay for some of the universal health care costs, and preventative care gets $4 billion. There is a tax credit for R&D work on energy innovations and renewable energy production of $20 billion, and $32 billion for a "smart electricity grid." These are the proactive parts of the stimulus that create something new and make improvements. They add up to $144 billion. So much money goes to shore up the existing services and supplement incomes, and to relieve stresses on the banking system, and other ways to shore up the system, that the proactive expenditures are only a small fraction or 17% of the $825 billion stimulus. And all the time the federal deficit and debt increases with these huge outlays just to shore up the system. The Heritage Foundation Data Analysis Director Mr. Beach told Congressmen at a discussion chaired by Congressman Cantor (R), on January 16, 2009, that the federal debt would reach 92% of the nation's GDP in 2009 from 58 billion or 70% in 2008, with the $825 billion for stimulus. The federal deficit would go up to $1.31 trillion or 9.2% of GDP up from $541 billion in 2008. See the research paper on the Heritage website. ...

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Rick Perry faces criticism from Republican candidates Romney, Bachmann, Huntsman and Paul at the Republican presidential candidate debate in Tampa on September 12, 2011. Perry defended his remarks on Social Security by telling viewers- "slam dunk guaranteed that program is going to be in place." Romney suggested Perry had been served four aces for his jobs record in Texas. And Santorum accused Perry of providing education assistance to illegal immigrants to attract the Latino vote. Perry defended his remarks on Fed chairman Bernanke printing money amounting to treasonous behaviour.

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The Congressional Budget Office analysis of the Republican healthcare plan advocated by Mr. McConnell, Senate Majority leader, is that it would add 22 million uninsured if implemented. That plan ran into opposition from Republican Senators Collins, Capito, Murkowski, Paul, and Moran, and lacked enough support in the Senate. All Democrats opposed it and with the thin majority Republicans were divided. By taking away some benefits given under the existing Affordable Care Act the plan hurt the elderly and low income people, making some Republicans listen to their constituents in home districts and not the Republican leadership. The NYT profiled two in particular who astonishingly in a sign of today's strange politics were the only ones publicly holding townhall type meetings to hear the views of people in their voting districts- Susan Collins of Maine and Jerry Moran of Kansas. Both senators were listening to rural communities and Moran stated his opposition with the words- "I am a product of rural Kansas." With it the nation takes a breather and the message goes out that it is best to listen first and then to seek middle ground, not do what both parties Democrats and Republicans did in 2009 and 2017- rush serious legislation through without support across party lines and without serious discussion.   ...

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The tough job President Obama faces as he faces opposition from politicians who have interests to protect, and healthcare businesses with interests to protect. The President has to come up with a plan that is deficit neutral, because financial markets could see a healthcare bill that further widens the deficit as a signal for higher interest rates that would deepen the recession. At the same time each of the three sources of revenue puts him at loggerheads with political leaders in Congress or groups with interests to protect. Limiting income tax deductions for high earners could raise $267 billion in 10 years. It would require taxpayers in the top tax brackets deduct their mortgage interest, state and local taxes, and charitable donations, at the 28% tax rate instead of the 33% and 35% tax rates. The opposition is with democratic leaders that it would hurt charities, universities that depend on tax deductible donations, and taxpayers in high tax cities like New York city that are the home base of Democratic leaders. Yet only 1.4% of households would be affected says the nonpartisan Tax Policy Center. The Center on Philanthropy at Indiana University, says charitable giving would decrease by 2%. The other opposition on this comes from the preference of Senators Baucus and Grassley, who head the Senate Finance Committee, for tax increases or cost savings to come from the health sector. Specifically they want to see the value of workers' employer provided health benefits subject to income taxes. It is a situation in which every sensible person admits the need for healthcare reform and would see the current pace of healthcare costs as unsustainable and dangerous; and after that will just go back to his group and try to preserve as much of the status quo as possible, so as not to disturb by much the benefits or compensation they have secured from the system over the years. Then there are political leaders in Congress with their own preferences, and Congressmen who are the subject of heavy lobbying by these interests. The administration and the Presidents job is to navigate this stream with a workable deficit neutral plan, without any requirement for any group to make sacrifices, and in some situations even small sacrifices for the public interest. Would charitable institutions be hurt that much, what if charitable institutions were exempted, why would other interests the try to obtain the same exemption. Its like the unions trying to keep the old unsustainable goldplated healthcare and other benefits at GM even as the ship was going down. Taxing employer provided employee health benefits as income would raise $2.5 trillion over a decade. The opposition here is from unions which are a force in the Democratic party and which count tax free health benefits as a legacy of the labor movement. Employer provided health insurance covers 160 million American employed and their dependents under the age of 65, so it has a wide impact. Yet most economists favor ending the tax break. They say it mainly goes to upper income taxpayers, and discourages cost consciousness among consumers of health care, thus encouraging excessive spending and surging health care costs. Senior Obama advisors, Peter Orszag, the budget director, and economist Jason Furman favor this approach. So do Republicans in Congress. Senators Baucus and Grassley are not asking for the complete removal of the tax break, what they want to see is capping the value of benefits that go untaxed. If the tax-free limit is $13,000, a policy worth $15,000 would pay income taxes on $2000. A third spource is to spend less on Medicare. About two thirds of the $948 billion in savings Mr Obama has proposed over 10 years comes from a number of reductions in Medicare spending. $177 billion comes from insurance companies bidding for government reimbursements for offering private plans to seniors. $106 billion comes from cutting the subsidies to hospitals serving the uninsured as universal coverage should remove this need. And $110 billion in reduced payments to hospitals and doctors because of productivity gains. A range of industries insurance companies, hospitals, doctors drugmakers, nursing homes, home health care companies and medical device makers, all stand to lose from reduced payments from Medicare and Medicaid. And these groups with interests to protect are another factor in this process of working out a healthcare plan. ...

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The startling truth about health "reforms," - they won't control spending, and without that the whole system of health care will rapidly become unaffordable and unsustainable. Obama's Council of Economic Advisors points out in new report that since 1975 annual health spending per person, adjusted for inflation has grown 2.1 percentage points faster than overall economic growth per person. At this rate health spending which was 5% of the GDP in 1960, and is 18% of GDP today, would grow to 40% of GDP in 2040. Medicare and Medicaid would increase from 6% of GDP now to 15% in 2040, or equal to three fourths of federal spending. Employer paid insurance premiums for families which grew 85% in inflation adjusted terms from 1996 to $11,941 in 2006, would increase to $25,200 by 2025 and $45,000 in 2040. This would force employers to reduce take home pay. Samuelson says the uncontrolled health spending is singlehandedly determining national priorities, reducing discretionary income, raising taxes, widening budget deficits and squeezing other government programs, while it is producing large amount of waste in medical spending. See the link to Prof. Tyler Cowen of George Mason University in NYT, 6/14/ 2009, who cites the habit of doctors to write many expensive tests as one of the prime culprits in the wasteful spending. And in the process it delivers higher cost for lower overall quality of health for the American people. This at a time when many European countries provide live examples of doing it in a better way- lower cost, better health. The serious problem with the Obama health reforms says Samuelson is that it talks about restraining spending but may end up increasing spending. Its talk about controlling spending he says is good intentions, but based more on hopeful thinking, public realtions and risks becoming cosmetic reform. Because to really control spending will require coming to grips with its fundamental cause- hospitals and doctors are paid mostly on a fee-for-service basis and reimbursed by insurance, private or governmental. Such a system encourages doctors and hospitals to provide more services, expensive tests, favors heavy use of expensive medical technologies to increase profits, and for patients to expect them. Samuelson puts his finger on the root of the problem - there is no incentive and every disincentive for all the players in this game , doctors, hospitals and patients to seek reform of this system. For doctors and hospitals the hope would be that this cosmetic "reform" would leave the system basically unchanged, and patients to continue with a lifestyle and expectations that do not not acknowledge the fact that a lot of healthcare does not come from spending but from preventative care, education, good eating and exercize habits, and healthy lifestyles. And the uninsured are no exception, they would simply start consuming the expensive care for lower quality of overall health like everyone else. With this kind of situation confronting us, the views of Samuelson, and Professor Tyler Cowen of George Mason University, as welll as a growing chorus of informed public opinion on this subject, is that insuring the uninsured is a good idea, but doing it within the bounds of the present system, can only increase the costs. And too much is at risk, to rely on what Samuelson calls a scattershot of measures to control costs made up by Congress such as "evidence -based guidelines," "electronic record-keeping," "bundled payments to hospitals, to give the illusion of progress that won't make a serious difference. A sweeping restructuring of health care is needed, that would overhaul "fee-for-service" payment and reduce the fragmentation of care. It will also need what has not even be touched on adequately in the debate. This is the massive need for education in the schools about nutrition, eating, exercize, healthy lifestyles. It would also require opinion leaders in each field from sports and other fields to lead by example and with constant public presence, the media, and companies to form a partnership with private institutions to change existing eating habits and lifestyles that encourage obesity, smoking, fast food eating habits, large portions in restaurants....

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With the rushed approach adopted by the Trump administration not enough consideration was given to winning support in the House from 25 conservatives in the Freedom Caucus. Without their support the bill cannot be passed in the House of Representatives. The fight also includes one over what are essential health benefits including whether  maternity care would be included. As a result some moderate Republicans are also expressing opposition on the grounds that less people will be covered and fewer benefits will be provided under the Republican House plan called AHCA. President Trump has not involved himself in the details, and the bill comes very early in the first 100 days, leading to the perception that health care has become a partisan conflict without really grappling with the problems of high cost of health care and creating a solution that all can support. Democrats are seen as having made the same error early in Obama administration's first term. President Trump sees this as a much needed win with a drop in his approval ratings, making this even less of an effort to come out with a good plan.  ...